Subtalar Joint Arthroscopy

Thomas Vitale, DPM discusses the technical aspect of arthroscopy of the subtalar joint. Dr Vitale also discusses proper port placement and potential risks of complications to consider. He also reviews both diagnostic and therapeutic techniques.

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Thomas Vitale
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Lecture Transcript

TAPE STARTS – [00:00]

Male Speaker: We are now pleased to welcome up Dr. Thomas Vitale from the New York College of Podiatric Medicine. He’s a professor in Surgical Sciences. He’s going to talk about subtalar joint arthroscopy.

Thomas Vitale: Thank you. I appreciate being able to lecture here today. I’m going to lecture on subtalar joint arthroscopy.

The subtalar joint, generally, is a very complex joint bone mechanically and diagnosis of subtalar joint pathology can be elusive even with the most sophisticated radiographic and radiological studies.

Arthroscopy offers the opportunity for you to directly visualize the joint and identify pathology and treat it. You know, we have in the profession in orthopedics, a general term of sinus tarsi syndrome but there’s an increase consensus that sinus tarsi syndrome is a general term and there is actually other issues that occurs in the subtalar joint pain and the subtalar joint arthroscopy will enable you for perform that.

So basically today what I’m going to do is I’m going to go over the anatomy and indication for pathology for the subtalar joint, go over the portals and show you the technique for arthroscopy and hopefully I have a video showing that in actual arthroscopy in the subtalar joint. There’s a 50-50 chance of it, it’ll work.

You know, there has been an increased emphasis in the medical literature and medicine in general that go to minimum incision surgery. Endoscopy and arthroscopy included in that, has always been at the forefront for decades. What has really occurred in more recent times, is technology has advanced itself to such a point that not only can we go into a joint, we can go into extra articular structures such as tendons and other cavities to be able to identify various pathology and treat it.

And the advantages are, just generally, and specifically through arthroscopy, you can get a direct visualization of pathology. You have less complications, you don’t have a big open incision. It’s very much quicker recovery and patients generally have less pain. Dependent on the procedure, a lot of times these patients are walking the same day.

The downside of arthroscopy in subtalar joint arthroscopy is a very big learning curve. And frankly, every time I’m doing arthroscopy, I am always learning something more. And you have to be very proficient in the anatomy because if you’re not, you’ll not be able to identify the pathologic processes.

From a historical perspective, Parisien was the first to describe subtalar joint arthroscopy cadaveric studies and introduced the technique in the anterior and posterior portals. And then in 1986, they actually did a clinical case study of actual subtalar joint arthroscopy, so it’s a great result.

Frey in 1994 compared the portals for subtalar joint arthroscopy and respect us to safety and visualization, and also introduced a middle portal and generally found that the middle portal is probably the least of act to have any type of damage.

And then Richard [Lendeen] [03:12] from our Allen Podiatric Literature in 1994 described ankle and subtalar joint fusion.

So generally, the functionality of an arthroscope is predicated on your ability to visualize joint pathology. And this is done by several maneuvers techniques to be able to accomplish that. And that’s regardless of what joint you’re identifying.

So when you talk about the function of arthroscope, one of the first things is called scanning. And I will just go over this generally just to get everyone on the same page is, for us what the technique is. And basically it’s a side-to-side and up-and-down motion use to examine a joint. Usually this is done sequentially. At least you try to do it sequentially, but dependent on amount of pathology that is in the joint, you may end up and do and identify every structure.

And here, you can see subtalar joint arthroscopy. On your right, that is the anterior aspect of subtalar joint, just posterior to the anterior process and calcaneus. The middle picture is a, again, going further posteriorly, and the last picture is a posterior subtalar joint itself. And so it’s sequentially identifying and looking at the structures. Now, this is ideal, in most of the time, you’re not going to have this great beautiful picture.

Then you have pistoning, pistoning is basically a technique by way to [indecipherable] [04:32] withdraw the arthroscope in order to observe the joint and change your field of view. When you advance your arthroscope as in the right-hand picture, you basically are decreasing the field of view but increasing size of pathology. When you’re withdrawing the arthroscope, you are increasing your field of view but decreasing the size of pathology as you can see on the right-hand side.

But then you have rotation. Rotation technique which is, you know, self-explanatory. You rotate the arthroscope in order to observe pathology.

[05:00]

Now, what you see is going to be predicated under prism and inclination of your arthroscope. A 0-degree arthroscope will give you no change degree in your peripheral picture. Now, if you have a 30-degree arthroscope, you can get a central overlap and you’re going to be able to see increase peripheral picture of what’s going on in the joint.

And then you have 70-degree and even 90-degree arthroscopes where you have a central area that you don’t observe anything but you see have an increased peripheral vision, especially in joints that have big turns or it takes in the shoulder, that works very nicely, and also technically for the subtalar joint as well.

And then lastly, I think the technique that is most important, is triangulation where you’re able to visualize your pathology, you visualize your instruments and either do a diagnostic or an upper arthroscopy but you need to be able to visualize a structure.

Now, I will tell you, there are some instances, a lot of time, there’s instances, where I’m going to a joint, I can’t see anything. I have to blindly resect some of that soft tissue to gain access so I can actually visualize a pathology. And that comes with experience and like I said, I always learn something from each arthroscopy.

And here you can see, in a triangulation, the arthroscope is on one side, the shaver is on the other. I generally, especially angle, you put the shaver or uplift instrument in the side of pathology and the arthroscope on the opposite side technically with subtalar joint arthroscopy, depending on the portals, you can do the same thing.

So let’s talk about the anatomy of subtalar joint. Now, subtalar joint basically is divided up into the posterior facet and that can be divided up into two portions, the anterior portion or those structures that are in the anterior aspect and posterior facet. They are anterior to the calcaneal fiber ligament and the narrow process talus includes synovium, and its anterior border is going to be the sinus tarsi in the [indecipherable] [06:51] calcaneal ligament and the cervical ligament. And there will be adipose tissue in this [indecipherable] [06:54].

And here you can see a picture from [indecipherable] [07:02] from Spain who actually recently passed away, but here you can see the posterior facet on your right and then the sinus tarsi on your left, on your right. And here you can – another picture again, you have the posterior facet, you have the anterior – the [indecipherable] [07:26] and cervical ligament which is anterior border of your sinus tarsi.

And here you can see in actual arthroscopic picture of superiorly, you can see, that’s the talus, and inferiorly, that’s the calcaneus, and anteriorly, the [indecipherable] [07:46] calcanean ligament and the cervical ligament.

And generally, and I want to get into the topic of medial subtalar joint arthroscopy, but typically, this limits your access the anterior and middle facet due to the structures although there are some techniques that this is resected and like I said, there will be a medial approach as well.

And here you can see again, this is actual picture going from anterior to posterior of the posterior facet of the subtalar joint with the talus superiorly and the calcaneus inferiorly and nice looking articular structure.

Then the posterior facet can be divided up into the posterior segment and those structures posterior to a calcanean of ligament in later process talus and it includes the posterior facet, later process talus, [indecipherable] [08:36], and soft tissue.

And here you can see again like a direct visualization, a calcaneus inferiorly here, superiorly, there is synovial tissues path [indecipherable] [08:45] obliterating these talus. And you can see the posterior view of the subtalar joint through a posterior tendoscopy – posterior endoscopy. Here you have [indecipherable] [08:58] superiorly is the ankle. The subtalar joint is the inferior joint.

And here you can see Stieda’s process and the flexor hallucis longus traveling down along that process.

Then you’ll have, anteriorly, you have the anterior talo-calcaneal in ventricular joint. Those are structures that distal to the cervical and [indecipherable] [09:16] ligament that they, including anterior middle facets like adipose tissue, et cetera.

It has been considered inaccessible because of the fact that they’re very tight ligamented structures and difficult to access. However, there have been some newer techniques where medial portals have been utilized, and we’ll get into that shortly. But here you can see again all the structure that are anterior to the sinus tarsi.

Like I said, you can see how difficult it is to get into the subtalar – the anterior aspect of the subtalar joint with any ease and here, like I said, because of the tissues that are there. Like I said, some techniques resect this, and to me, that’s counter intuitive because now you’re creating an instability of the subtalar joint.

[10:00]

So what are the common portals? Well there are three common portals, you have the anterior lateral portal which is essentially 2cm anterior to the tip of fibula, and 1cm distal, and is located in the – basically in the sinus tarsi, the most anterior aspect of the sinus tarsi.

Then you have the posterior lateral portal which is anterior to tendalchillis just anterior to it, and usually at the level of the tip of fibula, slightly 5- to maybe 1cm proximal to that. Because remember subtalar joined slopes proximately, posteriorly, you have to be careful that you don’t invade the ankle joint when you’re producing that.

Then you have the medial or the middle portal which is in the most proximal aspect of sinus tarsi joint. And if you want to be technical about it, it’s about 1cm anterior to the tip of fibula and again located in the sinus tarsi.

And here, you can see those portals and you can do ancillary portals to these three portals, but being cognizant of the fact that you need to make sure and maintain at least a centimeter soft tissue bridge between them, A, because you’re going to collide with instrumentation, but B, you don’t want to have necrosis of your incisions.

And here you can see again, a picture from the Foot and Ankle Clinics in 2015 of the portals and how close together they are in relationship to the other structures, prono tendons, et cetera.

And you can see in actual arthroscopic picture, an actual clinical picture, the arthroscope anteriorly, in the anterior lateral portal. And then you have the operative instruments in the posterior lateral portal. You can see the light posteriorly through trans-illumination, identifying where that portal would be.

Then you also have posterior endoscopy, and this is going to be used for both ankle and subtalar joint. And you have medial and lateral portals. Your lateral portal is the same portal as I just discussed for anterior approach and it’s just anterior to the tendo Achilles aligning, tendo Achilles. And you can also have an ancillary portal, a little bit more distal but you have to be very careful as you can see that you can nick the sural nerve.

Now medially, you have a medial portal. And again, the medial portal is at the same level as your lateral hind foot portal. But again, being cognizant of the fact that you want to be just adjacent to the tendo Achilles and you want to avoid the neurovascular structures. And I’ll get into some of the structures at risk shortly.

Also, I should mention that, you know, when you talk about hind foot endoscopy, it’s not really a true arthroscopy because it’s an outside-in type of technique. So when you’re doing this, you have to actually resec any fatty tissue, the capsule, to gain access to the subtalar joint or to the ankle joint, as opposed to when you’re doing the anterior approaches, which is an inside-out where you’re actually doing purely a joint investigation and penetrating the capsule and identifying structures that are inside the capsule. So I kind tend to shy away from the posterior endoscopy because there’s a – for me, again, I think you’re going to be destabilizing the soft tissue structures and creating instability. Although reports have been, you know, quite good with it, but there’s – we need more studies.

And here you can see, from the perspective of our portals, you can see that from the posterior facet, your posterior lateral portal, your middle portal and your anterolateral portal are going to gain you access to the posterior facet as well as your posterior medial portal. But when you look at your anterior facet and middle facet, you are not going to be able to gain access through these traditional portals very easily.

And that bring us to the portals, the medial portals of tarsal joint. And this is for you access the talocalcaneonavicular joints. McHale described in 1995 a medial portal that really was through to tarsal canal. Some of the technique, if you can do and arthrodesis where you started laterally, put a probe through and then opened the skin when you saw a tenting of the skin.

Hamon described some anterior approaches, the lateral midtarsal portal and the medial midtarsal portal, and where we can gain access to the talocalcaneonavicular joint and to the anterior middle facet. The tarsal canal portal is the one that I think is the easiest to perform and gives you the most information.

And Lee in 2012 did a whole study on that and showed that it was very effective. And basically, what you’re doing, you’re going to clear up the sinus tarsi via your shaver. You’re going to – and you’re going do that either through your anterolateral and your middle portals. You’re going to – under arthroscopic guidance, you know, so much you’re going an arthrodesis, you can put a probe or a K-wire and insert it through the sinus tarsi into the tarsal canal. You confirm your position with arthroscopy and then you make a medial tarsal portal.

Importantly here is that make sure you keep the foot pronated because you’re going to want to open up the medial aspect of the joint, and then you perform your examination. This is not without risk, which I’m going to show you shortly. But here you can see those – the portals and how that will gain access to –

[15:00]

gain access to the middle facet and the talocalcaneonavicular joints. And then you appreciate all the other portals here where the posterior facet is the facet that is most easily accessible.

And here you can see, again, how through the mid – through the tarsal canal portal, where you can gain access to a good portion of the anterior aspect of the subtalar joint but also you can get into the – look at the posterior facet as well.

So what are structures at risk? And here it’s very, very important, again, where anatomy comes into play. For your anterior lateral portals and to your midtarsal cutaneous nerves at risk, as well as your sural nerve and also your extrinsic complexes.

The middle portal, again, like I said, a fray, they did their study and showed that that really had very, very minimal risk to any structures that are in the vicinity. And then, of course, your posterior lateral portal, obviously, you have to worry about your sural nerve, and your small saphenous vein, and also your peroneal and Achilles tendons. You can very easily nick them and you have to be cognizant of the fact you could cause significant damage.

And the medial portals, flexor hallucis longus, the tibialis posterior, tibialis anterior and obviously you’re posterior tibial nerve and artery, your neurovascular structures. So you have to be – again, have a very good confidence level as far as your anatomy goes.

Now, a fray to the study, like I said, in 1994, and so the posterior portal had the greatest risk of damage. And with the middle portal, a minimum risk.

Tifundus, in 2008, did study on subtalar arthroscopy, a statistical analysis, and they did this on cadavers and found that the anterior middle portals were much more safer than the posterior portals. And that makes, you know, common sense. And Lee – Lou in 2013, did study of the tarsal canal portal. And here, you have to be careful dependent on where that – when you are making that portal. There was an increase of injury to the flexor hallucis longus into the posterior tibial neurovascular structures. So you have to, like I said, be confident in arthroscopy and confident in anatomy before you would even attempt those medial portals.

So what are the structures at risk, generally? And again, this is from Paogalinos, from the Foot and Ankle Clinics great anatomy pictures. But the thing you have to appreciate, you have your intermediate dorsal cutaneous nerve, you have your sural nerve and your peroneal tendon. So on – and here is your fibula. So here, you have to be cognizant of where these structures are, because as I said, you can damage them. Probably more the sural nerve than the intermediate dorsal cutaneous nerve. But sometimes there is a branch that will go from the sural nerve to the intermediate dorsal cutaneous nerve that you might potentially nick.

Your posterolateral approach again, sural nerve is coming down here and the small saphenous vein. You could see when you are doing your tendo Achilles – adjacent to your tendo Achilles Achilles how close you can come to these structures and how easily these can be damaged. And so you want to be as close to the tendo Achilles as you can. Of course, there’s anatomic variation that, you know, we can’t account for.

Now, posteriorly is a whole other ball game. And like I said, the issue is, here’s a tendo Achilles. Is that – this structure right here is the flexor hallucis longus. That’s the structure of – that you want to always try and be lateral to. If you go immediately to the structure, look what you are going to hit. You are going to hit your posterior tibial tendon and nerve and arteries. And so I want to show you shortly the technique that you utilize in there. And also meet laterally the small saphenous vein and the sural nerve.

So here you can see, when you’re doing a portal for posterior endoscopy, you’re going to make – draw a line from the tip of the lateral malleolus to the tendo Achilles and make your portal. Your portal, you make a stab incision and you’re going to insert your arthroscopic probe straight down but slightly angled medially toward the first interspace so that you avoid your lateral neurovascular structures.

Then your medial portal is at the same level as your lateral portal, as close to and adjacent to the tendo Achilles. And what you’re going to do is you’re going to insert your arthroscopic probe perpendicular to the arthroscope, which is lateral, and actually touch it and then run it down the arthroscopic probe until you come to the tip. Again, avoiding your medial neurovascular structures. You want to be lateral with your structures here. And then we need to do, though, unfortunately, like I said, you have to be resec soft tissue, adipose tissue capsule, in order to gain access, you use a subtalar joint or to the ankle joint.

So what is the technique? Well, anesthesia, you can be anywhere from local to spinal to general, you know, it’s your preference. My preference is generally if I’m doing an additional, combined or open procedure, I will use general anesthesia. But if I can, I’ll do MAC and also I’ll use local with epinephrine.

[20:00]

And I apply a tourniquet but I don’t use a tourniquet. And there have been – studies have shown that this is a much better way to perform the procedure. A, the patient doesn’t have to have pain and using epinephrine creates a vassal constriction within the synovium so you can get a good arthroscopic examination.

So you identify your portals, okay. You then inflate the capsule with fluid. Ankle joint 20, 30 cc. Subtalar joint, probably about 15 to 20 cc can easily get into the joint. And if it doesn’t want to expand, that gives you an indication that that patient may have an adhesive capsulitis or arthrofibrosis within the joint that is causing the pathology.

Now what you need – what you need to do then, you make your stab incision. I like to be parallel to tendon structures because if I’m – or neurovascular structures because if I’m perpendicular or horizontal to it, there’s an increased chance for me damage them. It is just going to be through the subcutaneous tissue, okay? Then you go into – do a blunt dissection down to the capsule. Now, some people will penetrate the capsule. I feel that, why penetrate the capsule with the hemostat when I want to take the arthroscopic oftorate and start with that so that you get a good and see all round instrumentation. And then, you’ve just – I said you nick and spread technique where you’re doing very little damage. Penetration of capsule with the – with the ofterate and then you insert your arthroscope.

So arthroscopy can be basically divided up generally into diagnostic and operative. So what are we looking for is for a subtalar joint. Looking for assessment of the articular surface. Now, here is the talus and this is calcaneus. It is a nice looking articular surface. This is the posterior for set.

Here, you can see now, we’re looking more anteriorly, the anterior process of the calcaneus is here. But here you can see that there’s a wispiness here, there is a neovascularization on top of the articular surface. There is some sort of process that is occurring within – on the articular surface. In this case, a beginning of an adhesive capsulitis. And here you can see, again, looking more posteriorly, this is still the calcaneus – this is still the calcaneus and you have significant synovitis here.

Now, further posteriorly, looking at the posterior facet proper, you can see the joint is obliterated, the articular surface is being vaginated, invaded by the synovium. And this is a patient who is misdiagnosed with ankle pain which really came out to be subtalar joint pain. I see that all the time that the joints are so close together that you can sometimes have an issue with the differentiation of these structures.

And then here you can see, again, articular surface. This is all frayed and there’s fissures within on the calcaneus in the subtalar joint. And here you could see significant arthrosis. This is the interosseous talocalcaneal ligament. This is the anterior process the calcaneus. This is the beginning point of the posterior facet. But look, the bone is exposed, there's very little cartilage here, this is a severely arthritic joint.

So now, the most common thing you're going to see if people who have persistent joint pain, unresponsive to surgical treatment, diagnostic test, like I said, sometimes are not really diagnostic. And you would know if a patient complain of locking stiffness, swelling, popping and you can see within a sinus tarsi, this fibrous band here, the synovitis, and engorge with blood being more of an acute type – hemorrhagic type of synovitis.

And you can see again fibrous band running between the talus, which is over here, and the calcaneus, and this can also be a source of pain. And remember, this is magnified so it's not as big as we see. Here again, a significant fibrous bands that result in a pathology and inability for the joint to move.

And here, you could see a more severe case, hemorrhagic synovitis. The calcaneus is down here, talus is up here and hemoglobin to the articular surface. But the articular surface of the calcaneus is totally obliterated. Again, consistently with a hemorrhagic synovitis and a process, hence, the term synostosis syndrome, this was an intense synovitic adhesive capsulitic type of process occurring.

Now, when you examine a joint, I mentioned we need to do a sequential examination. Eric Ferkel is the one who discussed this in both the ankle on the subtalar joint. And basically for the ankle we described, the 21 point exam in the subtalar joint, he describes the 13 point exam, one from the anterior lateral portal where you do to six point of an examination, you can see it here, and then the posterior lateral portal do a seven-point examination. I'm going to tell you that complete visualization and being able to do this great exam, most of the time, doesn’t occur. If it does, then you’re doing an arthroscopenic joint that they need to be – have arthroscopy done.

So from a therapeutically operative technique, what can we do? We can do a synovectomy due to adhesions, five adhesive capsulitis, as you can see here. This is the calcaneus right here. The talus is up here. There's also synovitis and synovitis in the fibrous band.

Here, again, you can see significant intense synovitis in the inferior aspect of the talus.

[25:03]

This is the calcaneus and the posterior facet is this area right here. Then you can get into more of traumatic arthrofribosis, where I just think it's just an extension of adhesive capsulitis, when not only does the capsule become inflamed and become hypertrophied, but it becomes fibrous and becomes very, very hard resulting in, again, obliteration of the whole joint surface. The calcaneus is down here, talus is here. There's also synovitis and very virtually obliterating the whole joint surface which can be an intense source of pain due to the inflammatory process that occurs with it.

And you can see again a more exaggerated form where, again, the calcaneus is here, the talus is over here, the sinus tarsi is here and you have this proliferation of synovial tissue. Arthrofribosis, as I said, would be a better term like, as I said, than using the term sinus tarsi.

Then you can do articular surfaces, chondromalacia. Chondromalacia is the softening of the cartilage where you have fissures, peaks and values, fibrillation of the articular surface, as you can see here. And this is the calcaneus where you have damage to the cartilage, not to the subchondral bone.

Here, you can see again more intense form of it, this fissures are formed here, this is again a calcaneus where you have significant erosion of the articular surface and you can get erosion right down to the bone.

And here, you can see chondromalacia occurring here. Then right here is going to be our next topic, and as chondral lesions. Now, Bauer and Jackson in 1988 on arthroscopy devised a classification scheme for chondral lesions in the knee, and it's applicable to any joint. You basically have six types. Type 1 is where you have this fissure of a linear crack within an articular surface. You have – type two is we have the stellate type lesion. Here, you have the cartilaginous flap in type 3. And type 4, you have exposed subchondral bone. And then 5 and 6, you know, fibrillation in subchrondral bone which is more consistent with chondromalacia.

And here you can see, like I said, this is chondromalacia here. This is a cartilaginous flap at the anterior aspect of the talus. The sinus tarsi is here. But this is resulting in potential pathology and probably rubbing against each other and getting a kissing lesion. You can see a more intense type of reaction.

And here, you can see again, this is the posterior facet, the talus is over here, and this cartilaginous flap and synovium that's invaginating into that flap, the source of pain. This patient had fallen from a height. The diagnosis of the – most of the oldest diagnosis were negative, went in and found this pathology occur.

And here, you can see again – more, again, this linear crack. That will bring us now to osteochondral lesions. Osteochondral lesions are lesions that are – go down to bone, and not just strictly cartilage. And here, you can see this linear crack, and this actually is full thickness that has a piece of bone attached to it. And that's it, it's not much different of any other joint. Here, you can see damage of the cartilage, but here is a transchondral lesion in the calcaneus and the posterior facet.

Other things that we can utilize it for, I mentioned impingement exostosis, tarsal coalitions, fusions, fracture assessment and in reduction. There is a big emphasis on utilizing arthoscopy during reductions of calcaneal fractures, ankle fractures, et cetera. And here is after the fact.

But also, we think we have such a great reduction when you go in and look at some of those – a calcaneal fracture. Look at this fissure that's here. The reduction is not as good as we think. And that's where why people feel you should be utilizing to develop a better reduction. And here again, look at this big fissure here. There's a big gap here and this is resulting in arthrosis and pain for the patient.

So a contraindication is relative as surrounding infection, PVD, a large amount of DDD, poor skin, equality in edema. Then we have contraindications that are absolute, obviously local cellulitis infections and severe PVD and DJD with ankylosis where you can't get the arthroscope into the joint.

Complications, infection, pain, DVT, nerve damage is common of all nurses I discussed. Hypoesthesias, paresthesias, chronic regional pain syndrome. Sometimes patients will get some, as I've said, the incision side, injecting down the road with a little bit of steroid usually takes care of that. Vascular pseudoaneurysms, join a fusion hemarthrosis by putting too much fluid in, tending damage compartment syndrome and also instrument breakage, which you have to be very careful of because that can be done very, very easily.

Okay let's hope – can we stop the video? Okay. This is an actual arthroscopy of the subtalar joint. Now, there is significant synovium within this joint, the patient had subtalar joint paint. And here, the arthroscope is being utilized and all those techniques that I just showed to you to resect out this sinus tarsi and the synovium.

[30:06]

The shaver is coming from the middle portal and the arthroscope is in the anterior lateral portal. And you can see how slowly and tedious this is. Now, this will speed it up. I mean, if you don't have patients, I mean, sometimes this procedures can take an hour or two hours to resect out this tissue. Then if you don't have patients for this, then, you know, it's not like me doing a knee where it's much easier to have a bigger instrumentation which takes less time.

And you can see the shaver being utilized and you're observing the shaver. You keep the shaver on a reciprocating type of mechanism, so it's going forward and back so there won't be any jamming. And you can see the joint that – the subtalar joint become an opening as we're resecting out the articular surface of the synovium.

And you can see some of the talus kind of have been exposed here and the calcaneus is down here. But this is arthrofibrosis. This is – like I said, I think it's just an extension of an adhesive capsulitis where the joint is obliterated with this fibrous tissue that creates a significant amount of pain.

And you can see a significant tissue here. And as I said, we're just resecting that out, this video is almost done, and making a space and trying to take all these tissue out. And you can see how the joint is slowly being opened, and a methodical arrangement – motion that you're utilizing in trying to clear out this joint. And this can speed it up significantly to not bore everyone, but gives you appreciation.

And then – but this is what the joint looks like. Once we got it cleaned, here is the talus and here is the calcaneus and here is another view. After getting all of that fibrous tissue out, that joint was cleaned and the patient did fairly well.

And here's another patient with a calcaneal fracture. A 17-year old patient, a severe joint depression fracture, it was just casted. The joint space is pretty much obliterated. You can see a CT scan. It means that the posterior facet isn't horrible. I just didn't feel that doing a subtalar joint fusion or a triple at someone who's young of an age would be advantageous.

So it went in and, again, you can see all the scar tissue within the subtalar joint. You can see now, again, all of the synovium, the articular surface is here, so this has only resected out. And here, you can see, this is the anterior process. Now, you're going from anterior to posterior, the posterior facet is here, not the best quality, but able to clean this out to at least give this patient some time before they even have a fusion.

And here, you can see the old facture. I mean, the severely arthritic joints. You can very easily argue with this patient, he could have had a fusion. But the patient actually did very well and then went on to have one more additional arthroscopy due pain that occurred about a year or two down the road.

Suggested readings, I've put a whole bunch of things here and some of the references from the pictures I've taken. And thank you.